Category Archives: Sound Advice
A few thoughts from the last week of work
- I both love and hate the new work schedule. 12 six hours shifts are exhausting. Feels like all you do is work and sleep. But then we get four days off at the end of it…. which is pretty baller.
- Did a conscious sedation on a patient so we could relocate he mangled thumb. She had a pretty profound reaction to the propofol, taking a good 15 minutes to come back to acting like her normal self. At one point during her altered period she looks me dead in the eyes “Sir… you suck….balls!” Hilarious.
- I was expecting it to be quite in the ED over the labor day weekend. Instead it’s like all the nutter’s came out to play at once. We had 5 1:1′s going at once. It’s a 24 bed ED!
- I had one patient who was particular grumpy. I asked him why. Apparently it was raining pretty hard, so when the ambulance pulled up, they just laid on the horn until he opened the door. And when he did, the driver got on the PA and hollered “Get in the back of the truck!” So he did, and he was pissed about the lack of door service. No idea if it’s true or not.
And of course, the learning curve was steep as always. A couple of pearls and rules of the road from this past week
- “Two-fers are never sick, unless it’s poisoning, usually of the carbon monoxide variety” (A two-fer is a two for one patient room, usually two related kids in one patient room)
- Give a miligram of ativan to anyone with a complaint of seizure and alcohol is in anyway involved, even if not seizing. Cuts down on repeat seizures, admissions, mortality & length of stay.
- PE’s and EKGs – S1Q3T3 is actually pretty rare. The most common EKG finding in PE is non specific T wave changes. Then, inversion of T waves in the anterior leads.
And finally, what’s an ED shift without a little humor. There is one attending who drinks a two liter of soda every shift. When he was off seeing another patient, the other attending dermabonded the cap shut (skin glue with the strength of rubber cement). After a few moments of struggling the first attending simply shouted “GOD DAMMIT” and stormed off, only to reappear 15 seconds later with an 11 blade scalpel in hand and quickly decapitated his bottle of soda.
Another pearly email from one of the godfather’s of EM, and another random pic
Recently one of our docs talked on the phone to a relative of a patient and gave confidential medical information. Not a bad idea to keep the family informed, but no good deed goes unpunished. Of course he did not know exactly to whom he was speaking, he just was told it was a daughter. Amazingly, this was reported as a HIPPA violation, big time problems are possible. I know that we often call relatives, or speak to them, without patient permission, but we must be careful with this seemingly benign, and proactive policy. It’s hard to tell someone that you cannot tell them about their loved one in the ED, especially when they are critically ill, but you cannot do so unless you get permission. Best to document in the chart if you get permission verbally. Go figure this absurd law, which is a mine field for ED docs
Another pearly email from one of the field’s fathers, and another pic that has no relation at all
A colleague saw a healthy 4 y/o with a typical viral syndrome. In the nursing triage note one of many complaints was chest pain. The doc likely did not read that note, or ignored it, and never addressed it in the chart. He concentrated on abdominal pain and vomiting, which were also complaints. The child seemed OK, was sent home, and died 13 hrs later of myocarditis. Myocarditis sometimes has EKG and troponin abnormalities, but not always. They were not ordered. Not sure how this would have been different, but not addressing the chest pain will cream him on this one.
Axiom: Always read and address the nursing notes. If there was no chest pain, and he said, “contrary to nurse note, there was no chest pain on my detailed eval” or “chest pain investigated in detail and not relevant” he likely would have been better off. Imagine trying to explain this one to the parents or jury, of course everyone knows chest pain comes from the heart, dah….
Another pearly email from one of the field’s fathers, another pic that has absolutely nothing to do with it
FYI, if a patient calls the state, complaining that she did not get enough pain medication from the ED, the state will investigate us, and they did so today. We are OK but very bothersome to all involved. No real doctor issues involved.
Many psych and drug seeking patients are very savvy about how to complain, and also many real patients think that their pain is not addressed properly (one of our biggest dissatisfactions in survey). Bottom line: actively address pain, don’t fight over a few percocet or a shot of morphine.
This particular pts became agitated and had to be escorted out of the ED. The state said we “threw her out”. If only (I can dream) the doc filled out our absolutely wonderful and doctor saving AMA form, with “Patient refused to sign”, we clearly did not throw her out, she left against advice and we wanted her to stay. Such attention to detail will save you behind some day.
Got this email the other day from one of the veteran attendings in our program. Seemed to be some sound advice so I thought I’d pass it on.
Folks: We had a recent M&M where a very obnoxious patient demonstrated a classic case where the ED doc needed to step back and reassess, and not get sucked in by the absolute idiot he was trying to help. I hate these cases with a passion, and it will often get the best of anyone. Clearly the patient was a first class pain, with many reasons to truly hate him, but the situation was not handled ideally. This is EM in its most difficult scenario. No one knows what we put up with, it’s degrading, and insulting, but that’s life in the ED. I often succumb to the same mentality as happened here, but I have also seen the result in court.
Briefly, my understanding is that the patient was uncooperative to the point of essentially impossible to deal with. He was disruptive to the entire ED, demanded pain medicine, threatened and insulted the staff, but was offered only Tylenol/motrin. He refused proper xrays. He was escorted (thrown) out of the ED, refusing a sling, when he became totally unbearable, and showed up with a dislocated elbow the next day, still so obnoxious you wanted to shoot him. The single xray that was taken suggests a dislocation. There is no chart notation that a serious elbow injury was considered.
This patient is a nightmare, but 2 years from now the only thing that will be heard is that the doctor refused to give a patient with a dislocated elbow proper pain medicine so he could cooperate, and then they threw him out of the ED without making the correct diagnosis of a limb threatening injury. If he were psychotic drunk or drugged, all the worse for the doc since the poor patient was unable to comprehend his situation, and the doc needed to do that for him. Not my take, but that is what will be presented if this becomes an issue.
The patient was a perfect example of a “good riddance” approach. You are a jerk, insulting, and threatening, so get out of the ED, with copious chart notes documenting the patient’s bad behavior. “I told the patient he could lose that arm if he did not let us examine him, and he understood, and was not drugged or drunk” would be a great chart addition. In the heat of documenting the patient’s absurd behavior, that medical aspect was lost.
Perhaps there is nothing that could have been done differently, but cooler heads need to prevail.
1. Give even jerks proper pain meds or sedation if needed for evaluation. It’s only 1 med, not 100 percocet to go.
2. The diagnosis on the chart should be “probable fracture/dislocation of the elbow”, If you are right you are a star, if you are wrong, no one cares, you were being careful.
3. Get another Doc on the case, bow out of this one. “offered another physician to the patient” is warm and friendly charting.
4. “I told the patient he had a bad injury and could return anytime if he changed his mind” is a nice gesture.
5. Document the LACK of drug/alcohol effect, or psychiatric disease.
I am glad I was not the doc on this one, but I have been in the past, and made the same mistakes.